Residual Injury, Appearance-Related Concerns, Symptoms of Post-Traumatic Stress Disorder, and Depression Within a Treatment-Seeking Veteran Sample

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1 MILITARY MEDICINE, 179, 10:1067, 2014 Residual Injury, Appearance-Related Concerns, Symptoms of Post-Traumatic Stress Disorder, and Depression Within a Treatment-Seeking Veteran Sample Terri L. Weaver, PhD*; Kristen H. Walter, PhD ; Kathleen M. Chard, PhD ; Jeane Bosch, MPH* ABSTRACT This study explored the associations among injury-related appearance changes experienced during deployment/combat, symptom severity of post-traumatic stress disorder and depression, and body image distress within a treatment-seeking veteran population (n = 91). Thirty-three percent of the sample reported having an appearancerelated residual injury experienced during combat or deployment (n = 30). A subsample, who completed the body image distress measure (n = 69), was divided into two groups: those with an appearance-related residual injury (n = 22) and those without an appearance-related residual injury (n = 47). Correlational analyses revealed significant, positive correlations between body image distress and depression symptom severity. Results also showed a trend relationship between body image distress and post-traumatic stress disorder symptom severity for those with an appearance-related residual injury although correlations were nonsignificant among these constructs for those without an appearancerelated residual injury. Multiple regression analyses revealed that body image distress was a unique predictor of depression symptom severity, controlling for residual injury status. Implications of these findings for exploring the psychological impact of residual injury were discussed. INTRODUCTION Although physical injury is endemic to combat experiences, the pattern and mechanism of injuries has changed over the course of history. During the first Persian Gulf War, there was an increase in injuries to the limbs, but a decrease in chest injuries as compared to the Vietnam War. 1 Improved body armor has contributed to this reduction in chest injuries, but other patterns of combat injuries have emerged, in particular, higher rates of head and neck injuries. 1 Specifically, when compared with World War II, Korea and Vietnam, soldiers within Operation Iraqi Freedom (OIF) have experienced disproportionate numbers of injuries to the head and neck. 2 Moreover, the mechanisms of these highly visible forms of injury are primarily from explosive sources including improvised explosive devices, mortar, and rocket propelled grenades. 2 In contrast, during Vietnam, head and neck injuries were more likely to be a result of single penetrating injuries. 1 Explosive injuries have resulted in scores of military personnel with concussive, soft tissue, penetrating, and burn injuries. 2 By their nature, many of these injuries result in *Department of Psychology, Saint Louis University, 221 North Grand Boulevard, St. Louis, MO Veterans Medical Research Foundation, 3350 La Jolla Village Drive (151A), Building 13, San Diego, CA VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA Cincinnati Veterans Affairs Medical Center,3200 Vine Street, Cincinnati, OH kuniversity of Cincinnati School of Medicine, 260 Stetson Street, Suite 3200, Cincinnati, OH The content of this manuscript does not necessarily reflect the views of the Department of Veterans Affairs or the U.S. Government. doi: /MILMED-D lasting changes to appearance, disfigurement, and loss of function. In spite of these physical insults, the rates of postinjury survival for the most recent conflicts have risen to nearly 90%, due in part to improved body armor, medical services deployed deep within the field and efficient medical evacuation. 3 Taken together, both these growing trends in visible injury coupled with high postinjury survival rates have resulted in a burgeoning cohort of active duty personnel and veterans living with injury-related appearance changes. Injured military personnel not only experience physical hardship, but may also experience psychological distress, with numerous studies documenting higher rates of post-traumatic stress disorder (PTSD) and depression for those with combatrelated injuries. 4,5 These psychological reactions often develop over the course of injury recovery. 5 For example, one longitudinal study found that 78.8% (n = 483/613) of acutely injured, U.S. soldiers who were positive for PTSD or depression at 7 months post-injury had screened negative after the first month. 5 A composite, self-report measure of physical problems (including injury, pain, and discomfort) was a significant, unique predictor of PTSD and depression at both early and later time points post-injury. These findings suggest that psychological reactions postinjury may emerge over time as service members encounter the longer-term implications of their injuries, which may include physical problems and/or altered appearances. Given the growing number of military personnel and veterans with visible, injury-related appearance changes and the fact that injuries are associated with psychological distress, it is notable that researchers have not explored specific bodyfocused concerns, often referred to as body image distress, among these populations. Body image is defined as an individual s subjective sense of their body, focusing primarily, though not exclusively, on appearance and encompasses MILITARY MEDICINE, Vol. 179, October

2 behavioral, perceptual, cognitive, and affective phenomena. 6 8 Body image distress has received some attention as an injuryrelated psychological concern, following injuries such as burns and scars resulting from intimate partner violence injuries. 9 In addition, body image concerns have been associated with posttraumatic sequelae with one study finding that body image distress was a significant, unique predictor of PTSD, for those with intimate partner violence related marks or scars. 9 Another study found that body image concerns mediated the association between patient and injury variables and depression within a sample of burn victims. 10 This study was designed to extend current findings associated with injury, body image distress, PTSD, and depression to a sample of treatment-seeking veterans (n = 91). On the basis of previous research, it was expected that body image distress would be significantly and positively associated with PTSD and depression symptom severity for those with an appearance-related residual injury, defined as a permanent change to one s physical appearance as a result of the individual s deployment or combat experience. METHODS Measures All patients who met Veteran Affairs (VA) eligibility criteria and who sought evaluation for PTSD treatment completed a diagnostic and psychosocial interview with a clinician and were administered self-report questionnaires to determine appropriate psychological treatment. All study procedures were conducted under a waiver of written consent based on archival data, which was granted by the VA Research & Development Office and the local university institutional review board. The Clinician Administered PTSD Scale for DSM-IV (CAPS) 11 is a 30-item structured interview that corresponds to the DSM-IV criteria for PTSD. Diagnostic criteria were assessed based upon the veteran s index trauma (i.e., the trauma identified as most traumatic or distressing), which could have occurred in either military or civilian settings. The CAPS is considered to be the gold standard in assessing PTSD. In this study, the CAPS was used exclusively to describe the sample diagnostic status. The PTSD Checklist Stressor-Specific Version (PCL- S) 12 is a 17-item self-report measure of DSM-IV symptoms of PTSD in the past week and was referenced to the veteran s index trauma (e.g., the traumatic event reported as most traumatic or distressing). Individuals rated items based on a 5-point Likert scale (1 = Not at all to 5 = Extremely ) indicating to what degree they have been bothered by symptoms in the past week. The Beck Depression Inventory (BDI-II) 13 is a frequently used, 21-item self-report measure of depressive symptoms in adults and adolescents. Participants rated items based on a 4-point Likert scale with higher scores indicating more severe levels of depression. A subsample of Veterans seeking care (n = 69) were administered the Dysmorphic Concerns Questionnaire (DCQ) 14, which is a measure of body-focused concerns that tap into cognitive, affective, and behavioral realms. The DCQ is a 7-item self-report measure of symptoms with items rated a 4-point Likert scale. The items are summed to yield a single total score, with higher scores indicating greater appearancerelated concerns. Rather than assessing for a superordinate disorder, this instrument was designed to assess the broad construct of negative body beliefs. The DCQ was validated on treatment-seeking patients meeting criteria for an array of different psychiatric disorders including major depression, bipolar disorder, schizophrenia, and anxiety disorders. 14 In addition, a Health Assessment questionnaire was administered asking participants to describe the presence (yes/no), number (numerical value), nature (reported mechanism of injury) of any permanent, appearance-related residual injury resulting from deployment or combat, whether the appearance change is visible while clothed (yes/no) and length of time since receiving the injury resulting in the appearance alternation (months). Appearance-related residual injuries were operationalized to respondents as including marks or scars, change in skin coloration and/or functional impairment in which a part of the body no longer works correctly. Statistical Analyses Frequencies were calculated to describe the demographics of the sample, PTSD diagnosis, index trauma, and type of appearance-related residual injuries. Zero-order correlations were utilized to explore the associations between PTSD, depression, and body image distress among individuals with and without appearance-related residual injuries. Hierarchical multiple regressions were conducted to examine whether residual injury status and body image distress were predictors of PTSD and depression symptom severity. All analyses were performed using SPSS version 18 (SPSS, Chicago, IL) and a levels for statistical significance were set at a = RESULTS Demographic and Descriptive Characteristics of the Sample Data were collected from pretreatment assessments for male and female veterans seeking outpatient or residential treatment in a specialty VA clinic in a Midwestern city (n = 91). Participants were excluded from the study for the following reasons related to appropriateness for care: active substance dependence, current unmanaged psychosis or mania, a significant interfering medical condition (e.g., unmedicated seizure disorder), or the presence of suicidal or homicidal intentions (individuals with ideation but not intention were eligible). A majority of the participants were male (83.5%), Caucasian (69.2%), and married (38.5%). The mean age was years and the mean number of years of education completed was Participants were primarily veterans of Operation Enduring 1068 MILITARY MEDICINE, Vol. 179, October 2014

3 TABLE I. Demographic Characteristics of Sample (n = 91) Percentage Mean SD Age Education Gender Male 83.5 Female 16.5 Race White 69.2 African American 26.4 Hispanic 2.2 Other 2.2 Marital Status Married 38.5 Single/Never Married 24.2 Divorce/Separated/Widowed 12.8 Service Era Vietnam 26.4 Post-Vietnam 18.7 Persian Gulf 20.9 OEF/OIF 34.0 Diagnostic Status PTSD Positive 78.7 Subthreshold PTSD 5.3 PTSD Negative 16 Index Trauma Experience Combat 58.8 Adult Sexual Assault 17.3 Child Sexual Assault 5.2 Other Traumas 18.7 Freedom and Iraqi Freedom (OEF/OIF; 34%), approximately 21% served in the Persian Gulf, 26.4% served in Vietnam and 18.7% were Post-Vietnam veterans (see Table I). Approximately 79% of participants met full DSM-IV diagnostic criteria for PTSD. The most frequently reported index traumas were combat (59%), sexual assault (17%), and child sexual abuse (5.2%). One third of veterans reported appearance-related residual injuries. Examples of appearance-related marks or scars included scarring around the hairline, stomach scar, scars that took them back to Nam (Vietnam), arm scar from explosive devices, and a large scar on top of the head from collapsed ceiling. Participants also endorsed appearance-related functional impairment that included paralysis (trouble with) knees and back, I have a hard time picking my kids up and having a limp. In terms of body image distress, participants with an appearance-related residual injury scored 0.43 standard deviations above the mean score of the original standardization sample (M = 5.2, SD = 5.6), whereas those without an appearance-related residual injury endorsed levels of distress comparable to the standardization sample. 14 Inter-Correlations Among PTSD, Depression, Injury Status, and Body Image Distress Correlational analyses were conducted (see Table II) and revealed significant, positive correlations between body image distress and depression symptom severity (r = 0.61, TABLE II. Inter-Correlations Among PTSD, Depression, and Body Image Distress (n = 69) Variable M SD Residual Injury Positive PCL-S BDI ** 1.00 Body Image Distress ** 1.00 Residual Injury Negative PCL-S BDI ** 1.00 Body Image Distress *p < 0.05; **p < p < 0.01) for those with an appearance-related residual injury, although correlations were nonsignificant among these constructs for those without an appearance-related residual injury (r = 0.22, p = 0.13). Therefore, residual injury status moderated the association between body image distress and depression symptom severity. The difference between these correlations was statistically significant (r = 2.03, p < 0.05). Analyses also revealed a trend relationship between body image distress and PTSD symptom severity (r = 0.40, p = 0.07) for those with appearance-related residual injury. Upon examining the symptom clusters of PTSD, a trend relationship also emerged between avoidance/numbing symptoms (r =0.37, p =0.09) and body image distress for those with an appearance-related residual injury as compared to those without an appearance-related residual injury (r = 0.09, p =0.54). Body Image Distress as Predictor of Symptoms of Depression and PTSD Two hierarchical multiple regression analyses were conducted to examine whether body image distress was a unique predictor of depression and PTSD symptom severity (see Table III). In the first hierarchical regression predicting depression, residual injury status was entered in the first step followed by body image distress in the second step. Body image distress predicted significant, unique variance in depression symptom severity above and beyond that predicted by residual injury status. In the second hierarchical regression predicting PTSD, residual injury status was again entered in the first step followed by body image distress in the second step. Body image distress did not emerge as a unique predictor of PTSD, explaining only 2% of the variance. DISCUSSION This pilot study found preliminary support for body image distress as an area of concern for veterans with appearancerelated residual injuries resulting from combat or deployment experiences. Moreover, the magnitude of these concerns was clinically relevant for these veterans with body image distress MILITARY MEDICINE, Vol. 179, October

4 TABLE III. Predictors of Symptoms of PTSD and Depression (n = 69) Depression (BDI-II) PTSD B SE B b R 2 D B SE B b R 2 D Model Residual Injury Model ** 0.02 Residual Injury Body Image Distress * *p < 0.05; **p < emerging as a unique predictor of symptoms of depression, above and beyond the variance predicted by residual injury. Consistent with epidemiological data, injury-related appearance changes were common in this treatment-seeking veteran sample, with 33% of the sample reporting their presence. Similar to previous research with other civilian traumaexposed populations, body image distress was significantly associated with depression symptom severity for those with an appearance-related physical change. 10 Interpretations of these findings have ranged from views of dysmorphic body cognitions as part of general dysphoria to other perspectives emphasizing that these cognitions also reflect distinct aspects, specific to appearance and physical functioning. 15 For example, although symptoms of depression were significantly associated with the DCQ within the instrument standardization sample and depressive symptoms and the DCQ each predicted significant variance in a global measure of body image distress, the DCQ predicted unique body image variance controlling for symptoms of depression. 16 Moreover, a second standardization article used individual depressive symptoms (BDI) to predict the total DCQ score and found that the two BDI symptoms that were unique DCQ predictors were body-focused (i.e., feeling ugly or unattractive and being concerned about one s physical health), further underscoring the body-specific elements of the dsyphoria. 15 Implications for this study include the fact that veterans with appearance-related injuries and symptoms of depression may have distressing cognitions that intersect their emotional functioning, health, and appearance. This study not only extends the associations of body image distress and trauma-related sequelae to another form of trauma, but also to a predominantly male population. With some exception, appearance concerns have been disproportionately studied in women. 17 However, there is increasing attention to a male-dominant form of body image distressmuscle dysmorphia. Muscle dysmorphia is defined as a collection of attitudes and behaviors focused on an intense desire to gain body mass in an effort to achieve the muscular ideal. 17 Muscularity has also been associated with masculinity and several indices of dissatisfaction with muscularity have been associated with low self-esteem 18,19 and symptoms of depression. 18 Although the current body image concerns were more general, similar to muscle dysmorphia, it is possible that men s experience of postinjury appearance changes may be partly linked to other aspects of masculinity, particularly, if appearance-related changes are associated with departures from the masculine (social) ideal (e.g., lean muscularity and low-body fat). This study lacks information about the meaning of the appearance-related injuries for participants, including possible implications for muscularity and masculinity in the context of a military culture. Future research would benefit from further examination of the ways in which the appearance-related residual injuries may impact individuals cognitions regarding a broader sense of self, including selfconcept and identity unique to military culture. These cognitions are also important to examine as they may be content to focus on in psychological treatment. Unlike previous research, this study failed to find a significant association between injury, body image distress, and PTSD. Part of the reason for these null findings may be that the measure of body image distress was anchored to general appearance concerns, rather than linked to the specific injuryrelated change. Previous research has found that associations between PTSD and body image distress exist when body dissatisfaction, such as checking the extent of the appearance change and avoiding or camouflaging the appearance-related change, are specifically anchored to the residual injury. 9 It is also possible that the magnitude of the effect size was weakened by these more general questions rendering the small sample inadequate. Future research would benefit from use of a larger sample of veterans, assessment of body image distress anchored to the residual injury and exploring the potential ways in which the residual injury may serve as reminders or triggers of their combat-related origins. This study was limited by the sample size, the fact that participants were all seeking evaluation and potential treatment for PTSD and related symptoms, and that the assessment of body image distress was anchored to general appearance concerns. Nevertheless, these findings provide preliminary support for considering the potential role that appearance-related concerns may play in postinjury psychological functioning, particularly depression, and possibly PTSD. Given the fact that appearance-related distress has traditionally been the purview of women, it would be important for future researchers and clinicians to explore male veteran s appearance concerns within a context that does not diminish masculine identities. 20 For example, these explorations may include discussions that integrate the implications of injury-related appearance changes for functioning and quality of life in work and personal settings. Future research 1070 MILITARY MEDICINE, Vol. 179, October 2014

5 should aim to replicate these findings and to explore the potential meanings of these injury-related appearance changes within samples of combat-exposed veterans. ACKNOWLEDGMENTS We would like to acknowledge the staff at the Trauma Recovery Center at the Cincinnati VA Medical Center, especially the clinicians who administered the assessments and the data efforts of Lindsey Davidson, BA. REFERENCES 1. Rustemeyer J, Kranz V, Bremerich A: Injuries in combat from with particular reference to those to the head and neck: a review. Brit J Oral Maxillofac Surg 2007; 45(7): Belmont PJJ, Goodman GP, Zacchilli M, Posner M, Evans C, Owens BD: Incidence and epidemiology of combat injuries sustained during the surge portion of operation Iraqi Freedom by a U.S. Army brigade combat team. J Trauma Inj Infect Crit Care 2010; 68(1): Tanielian TL, Jaycox LH: Invisible wounds of war: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Rand Corporation, Available at dam/rand/pubs/monographs/2008/rand_mg720.pdf; accessed August 24, Koren D, Norman D, Cohen A, Berman J, Klein EM: Increased PTSD risk with combat-related injury: a matched comparison study of injured and uninjured soldiers experiencing the same combat events. Am J Psychiatry 2005; 162(2): Grieger MDT, Cozza MDS, Ursano MDR, et al: Posttraumatic stress disorder and depression in battle-injured soldiers. Am J Psychiatry 2006; 163(10): Thompson JK, Heinberg LJ, Altabe M, Tantleff-Dunn S: Exacting Beauty: Theory, Assessment, and Treatment of Body Image Disturbance. Washington, DC, American Psychological Association, Fauerbach JA, Heinberg LJ, Lawrence JW, Bryant AG, Richter L, Spence RJ: Coping with body image changes following a disfiguring burn injury. Health Psychol 2002; 21(2): Lawrence JW, Fauerbach JA, Thombs BD: A test of the moderating role of importance of appearance in the relationship between perceived scar severity and body-esteem among adult burn survivors. Body Image 2006; 3(2): Weaver TL, Resnick HS, Kokoska MS, Etzel JC: Appearance-related residual injury, posttraumatic stress, and body image: associations within a sample of female victims of intimate partner violence. J Trauma Stress 2007; 20(6): Thombs BD, Haines JM, Bresnick MG, Magyar-Russell G, Fauerbach JA, Spence RJ: Depression in burn reconstruction patients: symptom prevalence and association with body image dissatisfaction and physical function. Gen Hosp Psychiatry 2007; 29: Blake DD, Weathers FW, Nagy LM, et al: The development of a clinicianadministered PTSD scale. J Trauma Stress 1995; 8(1): Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM: The PTSD checklist (PCL): reliability, validity, and diagnostic utility. Presented at annual meeting of the International Society for Traumatic Stress Studies, San Antonio, TX, Beck A, Steer R, Brown G: Manual for the BDI-II. San Antonio, TX, Psychological Corporation, Mancuso SG, Knoesen NP, Castle DJ: The Dysmorphic Concern Questionnaire: a screening measure for body dysmorphic disorder. Aust N Z J Psychiatry 2010; 44(6): Oosthuizen P, Lambert T, Castle DJ: Dysmorphic concern: prevalence and associations with clinical variables. Aust N Z J Psychiatry 1998; 32(1): Jorgensen L, Castle D, Roberts C, Groth-Marnat G: A clinical validation of the Dysmorphic Concern Questionnaire. Aust N Z J Psychiatry 2001; 35(1): Grieve FG: A conceptual model of factors contributing to the development of muscle dysmorphia. Eating Disord 2007; 15(1): Olivardia R, Pope HG Jr, Borowiecki JJ III, Cohane GH. Biceps and body image: the relationship between muscularity and self-esteem, depression, and eating disorder symptoms. Psychol Men Masc 2004; 5(2): Bergeron D, Tylka TL: Support for the uniqueness of body dissatisfaction from drive for muscularity among men. Body Image 2007; 4(3): Hunt CJ, Gonsalkorale K, Murray SB: Threatened masculinity and muscularity: an experimental examination of multiple aspects of muscularity in men. Body Image 2013; 10(3): MILITARY MEDICINE, Vol. 179, October